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Reply to: fibreoptic tracheal intubation training using bronchoscopy simulation

Graeser, Karin; Konge, Lars

European Journal of Anaesthesiology: March 2015 - Volume 32 - Issue 3 - p 211
doi: 10.1097/EJA.0000000000000133

From the University Hospital Rigshospitalet (KG) and the University of Copenhagen and the Capital Region of Denmark, Centre for Clinical Education, 2100 Copenhagen, Denmark (LK)

Correspondence to Karin Graeser, Department of Cardiothoracic Anaesthesiology, Copenhagen University Hospital Rigshospitalet, 2100 Copenhagen, Denmark Tel: +45 35 45 13 17; fax: +45 35 45 44 37; e-mail:

Published online 7 August 2014


We thank Dr Badiger et al.1 for their interest in our article.2 Since our first study on the prototype,3 we have followed the development of the ORSIM virtual reality bronchoscopy simulator (Airway Simulation Limited, Auckland, New Zealand) and are pleased that the experiences of Dr Badiger et al. are positive with the commercially available version. Interestingly, their findings closely resemble earlier results published on the other virtual-reality simulator in our study (AccuTouch; CAE Healthcare, Montreal, Canada).4 However, it is important to acknowledge that neither trainees’ self-assessed learning gain nor their perception of simulation realism are valid measures of the efficacy of the training. Literature shows that we cannot trust self-assessment5 and the fact that trainees feel more confident after a training intervention should not be equalled to increased competence. The importance of realism in simulation is under debate and a recent review found only a minimal relationship between simulation fidelity and transfer of learning.6 Virtual-reality simulators can show a range of difficult airway scenarios, but only the most expensive ones provide haptic feedback. Tube advancement is a key component of fibreoptic intubation and can only be practised on physical models. No evidence favours virtual-reality simulation over practising on mannequins when learning fibreoptic intubation. The best possible way of practising the procedure remains to be established. In a recent randomised controlled study,7 we compared part-task training with whole-task training and found a positive learning effect in both groups but no significant differences in fibreoptic intubation skills between groups. Future studies should compare different approaches to training and ideally use blinded assessments of real procedures as outcome measures (transfer studies).

In conclusion, we agree that fibreoptic intubation should be practised in a simulated environment prior to performance on patients. Available, local resources should decide which teaching modalities to use.

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Acknowledgements relating to this article

Assistance with the letter: none.

Financial support and sponsorship: none.

Conflicts of interest: none.

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1. Badiger S, Fearnley A, Ahmad I. Fibreoptic tracheal intubation training using bronchoscopy simulation. Eur J Anaesthesiol 2015; 32:209–210.
2. Graeser K, Konge L, Kristensen MS, et al. Airway management in a bronchoscopic simulator based setting. Eur J Anaesthesiol 2014; 31:125–130.
3. Krogh CL, Konge L, Bjurström J, Ringsted C. Training on a new, portable, simple simulator transfers to performance of complex bronchoscopy procedures. Clin Respir J 2013; 7:237–244.
4. Konge L, Arendrup H, Buchwald C, Ringsted C. Virtual reality simulation of basic pulmonary procedures. J Bronchol Intervent Pulm 2011; 18:38–41.
5. Eva KW, Regehr G, Gruppen LD. Blinded by ‘insight’: self-assessment and its role in performance improvement. In: Hodges B, Lingard L, editors. The question of competence. Ithaca, NY: Cornell University Press; 2012. 131–154.
6. Norman G, Dore K, Grierson L. The minimal relationship between simulation fidelity and transfer of learning. Med Educ 2012; 46:636–647.
7. Nilsson P, Russell L, Ringsted C, et al. Simulation-based training in flexible optical intubation: a randomized study. Eur J Anaesthesiol 2014; [Epub ahead of print].
© 2015 European Society of Anaesthesiology